The Psychological Consequences of “Fat Letters”

Schools in 21 states measure children’s body mass index (BMI) to screen for obesity, and eight states require that reports be sent home to parents to encourage treatment for overweight kids. Proponents acknowledge that there is no evidence that these so-called “fat letters” help children lose weight; they are simply an “awareness tool.” Yet there is substantial evidence that this practice could directly lead to poor self-image and even eating disorders. Massachusetts has wisely ended the practice of sending “fat letters”; the remaining eight states should follow that example as soon as possible.

For obese children, letters home about their BMI are an official judgment that they are inadequate because of their size. “Fat letters” are delivered annually; thus, even when children are trying to make healthy changes, they could continue to receive up to a dozen of these letters throughout their school career.

The spirit of these letters echoes the societal sentiment that obesity is a problem that needs to be fixed. They also insinuate that children are to blame for their condition and that they lack awareness or willpower. And because “fat letters” are a collaboration between the child’s school, parents and doctor, kids are likely to feel that school officials, health care professionals and possibly their own parents are ganging up on them over their weight. This will simply validate their fears that they are somehow bad or subpar because their body is unacceptable. It can also increase cruelty among peers, as obese children are among the most stigmatized, teased and bullied groups of people.

This stigma can result in increased poor self-concept and unhealthy dieting behaviors. The result is a cycle of negative body image, rigid dieting and unhealthy eating that can last a lifetime, with devastating consequences. Adults who binge tend to be obese. Obesity by itself poses a host of health risks; having an eating disorder as well can substantially increase the risk for serious psychological problems—like depression—and health problems like diabetes and cardiovascular disease.

Through health screening and BMI measurement, schools want to motivate children and their families to reduce obesity. But sending regular letters home risks stigmatizing children and can lead kids to be anxious about intervention.

To date, there is a disturbing lack of studies done on schools using this program, and the studies being conducted do not adequately assess the potential risks of BMI screening. This trend reflects a more general problem of eating disorders being under-diagnosed among obese children. Doctors and family members too often view weight loss as a good thing, without assessing whether it’s occurring in a healthy way. This further suggests that any negative consequences of “fat letters” are likely to go ignored and undetected.

It’s unlikely that school officials want to perpetuate eating disorders and body-image issues among children. Fortunately, there are other, more effective ways to help ensure our children are healthy and happy.

• All states should retract the mandate to measure BMI in schools. While BMI is a reliable indicator of other health risks, using BMI alone to gauge children’s health and inform “treatment” plans can have serious negative consequences.

• Schools should focus on fully implementing evidenced-based community nutrition and physical activity programs for all students, regardless of their weight.

• There must be careful studies of “fat letters,” to address possible negative consequences.

• Advocacy groups that specialize in reducing the stigmatization of obesity and eating disorders must be involved.

Policy makers and advocates of BMI screening in schools have the best intentions. However, this policy blatantly overlooks the long-term, potentially devastating consequences of this practice for children. All states must take a step back from this program until we better understand not only its effectiveness, but the very real psychological impact as well.

These letters may not help because they are sent to fat parents who think eating is recreation. I'm not a fan of Dr Oz, but he did say that if you are fat, you probably have a fat dog, too, and THAT cannot be blamed on genetics.

Doctor Friedman seems to have an intense fear that students will be, as they say, 'scarred for life' if they receive a letter from school about their weight.

I do not believe people are so mentally weak, however much psychologists and their 'studies' insist we are...however, this focus on the possible harmful effects of the letters is stepping around the real problem, which is the child's obesity.

We must ask what is worse - some embarrassment a child may feel about being told they are seriously overweight, or the weight problem itself....?

As far as needing physical education programs based on 'facts-based research' said research seems to be a large waste of money to me. Fact is, Americans are overweight because we eat too much (just like we consume too much of everything) and are too inactive. Do we really need researches to tell us these things?

My medical practice was recently incentivized to "address" childhood obesity by one of the major health insurance companies. We had an additional reimbursement offered if we could document that we had "discussed" and "addressed" nutrition with any child above a certain BMI.

So, we had our nurse review all of the charts for children insured by that company, and she searched visits in the past year filtered by a threshold BMI and read the chart to see if modifying diet and nutrition was documented. (Electronic Health Records.)

If it wasn't documented, she'd call the family and say that the child's BMI was high and recommend a healthy diet, document it, and we'd become compliant with the health insurance's program. Getting the incentive was that easy, and, as you'll see, meaningless.

Many of the children who were above the threshold BMI had documentation of healthy nutrition counseling - the doctors could see who was "fat" without calculating their BMI. Most of the families who the nurse called said, "What? My son isn't obese, he's an athlete."

The muscle mass of athletic adolescents puts their BMI outside of the normal range. And, none of those patients had any documentation of a recommendation to lose weight. The doctors could tell who was overweight just by looking at them - no BMI calculation necessary.

The insurance company's program that used BMI to "capture" the obese children that were being missed just wasted time and money. NO ONE needs BMI to identify obesity. The parents, the doctor, the kid, AND the kid's peers know who's overweight without a calculator and, without a letter from the school.

Cornell University just did a pilot study on an intervention that may address the real issue - food choices.

It seems to me that a good, responsible school *should* be obligated to send a letter(s) of concern to parents regarding *any* type or form of suspected child abuse or neglect.

So, for example, if one of their young students is assessed as being badly *underweight*, literally starving or malnourished, would that not also prompt a letter of concern from school administrators? (a "skinny letter", I suppose it would be called?)

Deliberately overfeeding a child to obesity (or negligently allowing the child to over-feed himself/herself into obesity) IS a form of child abuse, equally as abusive as underfeeding a child or medically neglecting a child.

It indicates that the parents are either shockingly unconcerned about their child's health, or amazingly ignorant about proper child care, or possibly it indicates parents who are frequently physically absent due to work (or virtually "absent" due to substance abuse) which in any case constitutes child neglect.

Or, possibly it indicates parents who have some form of mental illness or personality disorder that negatively impacts their ability to parent well. A morbidly obese parent who allows her child to become morbidly obese may be in deep denial about the genuine negative health impact of morbid obesity on her own self AND on her children.

In my opinion, not only should letters be sent, but if the child abuse, maltreatment and/or neglect continues over time with no signs of improvement, then social workers from child protective services should be sent instead of letters.

Children under age 10 or so have very little ability to even comprehend that they're being neglected, abused, or exploited by their own parents. Its up to the child's relatives, teachers, coaches, neighbors, friends, pastors, and other responsible adults to notice and make a point of calling attention to suspected child abuse and neglect, so these kids can get help sooner rather than later.